Formative research to adapt a cardiac rehabilitation program to breast cancer survivors: the heart health after cancer treatment (HEART-ACT) study

Background Breast cancer survivors are disproportionately at risk for cardiovascular disease; exercise-based interventions may improve cardiovascular health. The objective of this formative research is to better understand the needs of patients and barriers to participation in an adapted cardiac rehabilitation program for diverse breast cancer survivors in an urban safety net setting. Methods We recruited 30 participants (10 English-speaking, 10 Spanish-speaking, and 10 Cantonese-speaking) who had received treatment with curative intent for breast cancer from an urban safety net hospital between November 9, 2021, to August 30, 2022. Participants completed surveys and interviews about perspectives on health behaviors and participating in an adapted cardiac rehabilitation program. Interviews were qualitatively analyzed using rapid template analysis with pre-selected constructs from the Theory of Planned Behavior, Unified Theory of Acceptance and Use of Technology, and Consolidated Framework for Implementation Research, as well as emergent codes. We developed a Participant User Journey for a program based on responses and conducted human-centered design sessions with 8 participants to iteratively revise the Participant User Journey. Results Among 30 participants, mean age was 56.7 years (standard deviation [SD] 10.2) with 100% female sex assigned at birth; 1 participant withdrew before completing study procedures. Most participants had limited health literacy (18/29, 62%). Mean body mass index was 31.4 (SD 8.3), 21/29 (72%) had blood pressure below 140/90 mmHg, and 12/29 (41%) had blood pressure below 130/80. Mean 6-minute walk distance was 384.9 meters (SD 78.3). The desired benefits of a program included healthy living and prevention of cancer recurrence. Barriers to participation included motivation, social support, transportation, and concerns about exercise safety. Participants emphasized the need for practicality, such as fitting physical activity into daily life and nutrition support, including recipes and shopping lists. Trusted experts and cultural and language concordance were viewed as important aspects of the program. Conclusions Through participant interviews and human-centered design sessions, we developed the HEART-ACT program, a 12-week multi-disciplinary program addressing physical activity, nutrition, emotional well-being, cardiovascular risk, survivorship, and other components if indicated (e.g., tobacco cessation). Future research will test the effects of this program on patient-centered outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s40959-024-00228-y.


Introduction and verbal consent (written informed consent not already obtained):
Hello, my name is -<insert name> from the University of California, San Francisco and I am a team member for this project.Alexis Beatty is the researcher in charge of this study.Thank you for agreeing to talk with me today.As we have discussed, you are being asked to take part in this study because you have a history of breast cancer and receive care at Zuckerberg San Francisco General Hospital (ZSFG).Today we are consenting you for the interview part of the study.We will ask you for signed written informed consent when you come to the clinic to complete the other parts of the study.
If you agree to this interview, I would like to ask you a few questions that will help us create a new program for physical activity, health, and wellness for women with breast cancer.The interview will take between 40-60 minutes of your time.There will be no direct benefit to you for participating in this interview, but the information you provide will help us create a new program that we hope will improve heart health in breast cancer survivors in the future.I am interested in all of your ideas, comments, and suggestions.There are no right or wrong answers.All comments, both positive and negative, are welcomed.Your opinion is important, and I want you to feel comfortable in saying what you really think.
The project team and I also want to make sure that we accurately capture all of your ideas; therefore, we would like to ask for your permission to record our discussion.However, we will keep this recording confidential and for use by people involved with the research only.Before we get started, I just want to remind you that your participation in this interview is completely optional.You should feel free at anytime to let me know if you need a break or if you do not want to talk about a certain topic or answer a question.You can also let me know if you want to stop the interview at any time.Consumers' cognitive tradeoff between the perceived benefits of the applications and the monetary cost for using them

Hedonic motivation
The fun or pleasure derived from using a technology

Technology use intention
Degree to which the subject has a plan to use a technology Unified Theory of Acceptance and Use of Technology -use to code for behaviors related to using technology include telephone, Zoom, mobile apps, wearables .

Intervention source
Perception of key stakeholders about whether the intervention is externally or internally developed

Relative advantage
Stakeholders' perception of the advantage of implementing the intervention versus an alternative solution

Design quality and packaging
Perceived excellence in how the intervention is bundled, presented, and assembled (quotes related to structure and delivery of the program e.g., in-person vs. video/Zoom)

Cost
Costs of the intervention and costs associated with implementing the intervention including investment, supply, and opportunity costs

Patient needs and resources
The extent to which patient needs, as well as barriers and facilitators to meet those needs, are accurately known and prioritized by the organization

E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E E 12 weeks Referral
Education (in-person) I = Individual Counseling (in-person or virtual) E = Exercise (on own or in community)Graduation (in-person) Education (in-person) I = Individual Counseling (in-person or virtual) E = Exercise (on own or in community)Graduation (in-person)

I
will send a referral to the HEART-ACT team and they will contact you about how to get started with the program.Education (in-person) I = Individual Counseling (in-person or virtual) E = Exercise (on own or in community) Graduation (in-person)

Assessment•
Questions about current physical activities • Six minute walk test (walk for six minutes and measure distance) Goal • Safely increase exercise intensity and duration Example Plan • Exercise prescription example: • Warm up: 20 minutes light activity (walking dog) • Exercise: After walking dog, walk 10 more minutes at somewhat hard exertion (or to a heart rate goal) every day (in-person) I = Individual Counseling (in-person or virtual) E = Exercise (on own or in community) Graduation (in-person)

III. Thank you/wrap up "
Do you have any questions before we begin?Would you like to participate in this interview?[Now start the recording.]If person consents, document in study record.Start interview.If you have questions about this study in the future, you can contact Dr. Alexis Beatty at 415-502-6191 or BetterHeart@ucsf.edu.If you have questions or concerns about your rights as a research participant, you can call the UCSF Institutional Review Board at 415-476-1814.Instructions for facilitator: These questions do not have to be read verbatim.They are topics to be used as a guide for steering the conversation.Generic prompts: If responses are limited or require clarification, probes may be used to elicit more detailed responses.Probes should use words or phrases presented by the participant using one of the What do you think of these topics?If we were to hold one session on each, what would you want to make sure is included? What else would you be interested in, that isn't on this list? Who/what kind of speakers would you like to have during these sessions? How do you feel about having male speakers/presenters versus female speakers/presenters?  *How do you feel about committing to 12 weekly sessions?o Are there specific days and times that would work best for you? *We want this program to be enjoyable and comfortable for people from many different backgrounds.What do you think we should do to ensure that this is the case?o Would you want to be meeting with the same or other patients each session?How do you feel about talking about yourself in the group? How would you feel about receiving exercise training?o [if talks about previous experience] PROBE: What did you like/dislike about that experience? *How would you feel about exercising with a group?o What if the group had mixed gender?o What if the group had people with multiple different health conditions (such as heart or lung disease)?(probe about only women who have had breast cancer?)Would you be interested in working with a Dietician?Pharmacist?Mental Health Care provider?o [if talks about previous experience] PROBE: Tell me more about that?o If so, on what topics? Have you used mobile apps to help with your health?o What did you like/dislike about using the app?  What should we call this program?Thanks for sharing many helpful ideas with us, and now we are coming near the end of our discussion, my last questions for you are…"  What other thoughts or ideas would you like to share? Any thoughts on how to engage people to participate in this program? What questions do you have?
The Better Heart Study: Participant Interview Guide V1.2, 10/11/2021 *What role, if any, does physical activity play in your life (physical activity can include exercise, leisure activities, housework, yardwork, and activities you do at work/occupation)?  PROBE: What role did physical activity play in your life before cancer diagnosis? PROBE: Did this change during or after cancer treatment?How?  PROBE: What types of activities do you do?  PROBE: What helps you to be active? PROBE: What keeps you from being active? PROBE: Why is physical activity important (or not) to you?How do you think physical activity affects your risk of breast cancer recurrence?How do you think physical activity affects your risk of heart disease?Did you know that physical activity reduces your risk of breast cancer recurrence and your risk of heart disease?PROBE: Have you talked with your primary care physician (PCP) or oncologist about this?II.Proposed program Now, I would like to talk about how the program might be structured.First, I'd love to hear what you are most interested in learning about/having the opportunity to do as part of a health and wellness program? *Can you list the top three things you would like to learn about/discuss in a group?Out of the three you mentioned, what would be your number one pick and why?The Better Heart Study: Participant Interview Guide V1.2, 10/11/2021  *We are considering holding sessions, on the following topics: o Physical activity o Nutrition o Stress management o Mindfulness o Survivorship o Sex & Intimacy (alt.body image and intimacy) o Sleep o Alcohol/Tobacco/Cannabis o Heart condition risk factors and medications  * *How would you feel about doing sessions by phone, video or both?Can you talk about any experiences you've had with clinic visits by phone or video? PROBE for challenges: What worked?What didn't work?etc.  PROBE: Are you familiar with the app called Zoom?   *How would you feel about exercising at home or in your community (YMCA or senior center)?o What would you need to start exercising?o Where would prefer to exercise? 12 weeks Referral 12 weeks Referral